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APPLICATION FORM FOR THE INDUSTRIES/INDUSTRIAL ESTABLISHMENT SEEKING

PERMISSION FOR OPERATING AS PER ORDER OF MINISTRY OF HOME AFFAIRS ORDER NO
40-3/2020-DM-I(A) DATED 15.04.2020.

I,Mr/Mrs…………………………………(Name), ................................................... (designation),

authorizedsignatoryof ......................................................... (Name of Establishment) located at
…………………………………………………………………………………………………..(address) solemnly
affirm and declare following in connection with application for seeking permission to operate from
dtd.20/4/2020 under Ministry of Home affairs order No 40-3/2020-DM-I(A) dated 15.04.2020.

1. I hereby, declare that, the following details are complete and true to the best of my
knowledge and based on records.

Name of Industries
Location
Taluka
District
Name of Contact Person
Designation
Contact details (Mobile No)
Email address
No of Employees + Contractual worker
Name of Product
Capacity

2. I have read, understood and agreed to comply with order and guidelines of Ministry of
Home affairs, Ministry of Health and family welfare, Various departments of Govt.
of Gujarat and District Administration
3. I declared that we had obtained all applicable and mandatory permissions to operate our
industry.
4. I will strictly follow all the Standard Operating Procedures (SOP) as per the Undertaking signed
& submitted herewith this application.
5. I confirm that we will comply with any future guidelines/order published by Government of
India/ Government of Gujarat and district administration.
6. I hereby declare that my factory is not closed down by any adverse order of Government Department
and/or Court of Law or any adverse incident.
7. I hereby, declare that, the following specific details in connection with Ministry of Home affairs
No 40-3/2020-DM-I(A) dated 15.04.2020 are complete and true to the best of my knowledge and
based on records.

6.1 Our industrial establishment is located in

Rural area/ Municipal Corporation/ Nagar palika
6.2 Our industrial establishment is located within area limit of Special (Yes /
Economic Zones (SEZs) / Export oriented unit (EOU)/ industrial No)
estate / industrial townships.
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6.3 Our industrial establishment manufactures essential goods including (Yes /

drugs, pharmaceuticals, medical devices, their raw material and No)
intermediates.
6.4 Our industrial establishment is continuous production process (Yes/No)
6.5 Our industrial establishment manufactures IT hardware (Yes/No)
6.6 Our industrial establishment is in Coal Production/mines and mineral (Yes/No)
production/mining operations
6.7 Our industrial establishment manufactures Packaging material (Yes/No)
6.8 Our industrial establishment manufactures Jute related product (Yes/No)
6.9 Our industrial establishment is in oil and gas exploration/refinery (Yes/No)
6.10 Others (Please specify)

7. I, hereby declare that, I shall be solely responsible for any kind of violation of order of Ministry of
Home affairs No 40-3/2020-DM-I(A) dated 15.04.2020, and shall be liable for punishment as
per the law of the land.

Date: Name, Designation and Signature of the

Authorized Person

Place: Seal of Industrial Unit

Note: In case of authorized person is signing this application & undertaking on behalf of the
company, authority letter shall have to be furnished duly signed by Directors/ Partners/ Proprietor
of the Company.

Attachment:- (1) Undertaking.

(2) Annexure.
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UNDERTAKING
With reference to our application to operate our industrial unit, we hereby undertake to strictly
adhered to following Standard Operating Procedure declared by Ministry of home affairs, Ministry of
health and family welfare, Various departments of Govt. of Gujarat and District Administration
1. We shall strictly observe social distancing in our factory premises. It shall be ensured that all
workers/employees shall wear the face mask.
2. All areas in the premises like Entrance gate of building, office, Cafeteria and canteens ,Meeting room,
Conference halls/open areas available/verandah/entrance gate of site, bunkers, porta cabins, Equipment and
lifts, Washroom, toilet, sink, water point, Walls/all other surfaces etc. shall be disinfected completely using user
friendly disinfectant mediums
3. The factory shall be operated with minimum work force. Arrangements for stay of workers/employees within
factory premises shall be made up to the extent possible. For workers/employees coming from outside, special
transportation facility shall be arranged without any dependency on the public transport system. These vehicles
shall be allowed to work only with 30-40 % passenger capacity
4. No worker/employee from the hot spot/containment zone/red zone shall be allowed in the factory premises.
5. Worker above the age of 65 years of age persons with co-morbidities and parents of children below the age of 5
years shall not be allowed in the factory premises.
6. All vehicles and machinery entering the premise shall be disinfected by spray mandatorily.
7. Mandatory thermal scanning of everyone entering and exiting the work place shall be done.
8. Medical insurance for the workers/employees (unless covered under ESIC scheme) shall be made mandatory.
9. Provision for hand wash and sanitizer preferably with touch free mechanism shall be made at all entry and exit
point and all common areas. Sufficient quantities of all the items shall be made available.
10. No overlap of shifts and staggered lunch with social distancing in canteen shall be ensured at factory premises.
11. Large gatherings or meetings of 10 or more people shall be discouraged. Seating arrangement shall be ensured
so that at least 6 feet distance maintained from each other on job sites and in gatherings, meetings and training
sessions.
12. Not more than 2/4 persons (depending on size) shall be allowed to travel in lifts or hoists.
13. Use of staircase for climbing shall be encouraged.
14. There shall be strict ban of gutka, tobacco etc. and spitting shall be strictly prohibited.
15. There shall be total ban on non-essential visitors at sites.
16. Hospitals/clinics in the nearby areas, which are authorized to treat COVID-19 patients, shall be identified and
list shall be made be available at work place all the times.
17. Records shall be maintained for thermal scanning & area sanitization within the premises & vehicles.
18. No adult worker/employee shall be allowed or required to work in a factory for more than 12 hours in any day
and 72 hours in any week
19. The period of work of adult workers/employees in a factory each day shall be so fixed that no period shall
exceed 6 hours and that no worker shall work for more than 6 hours before he has had an interval for rest of at
least half an hour.
20. No female workers/employees shall be allowed or required to work in a factory between 7:00 PM to 6:00 AM
21. Wages shall be in a proportion of the existing wages.
22. We shall follow all the instructions and guidelines related to buffer zone/orange zone and we acknowledge that
these zones are variable.
23. Intensive communication and training on good hygiene practices shall be taken up at factory premises.
24. I declare that my factory is not closed down by any adverse order of Government Department and/or any court
of law or any adverse incident.
We understand that any person/firm/company/entity violating these provisions shall be liable for prosecution
under the provisions of Section 51 to 60 of The Disaster Management Act, 2005, and also liable for legal action
under Sec. 188 of the IPC & other legal provisions as applicable.
I, hereby, commit that I shall abide by the above mentioned measures/provisions in letter and spirit.

Date: Name, Designation and Signature of the

Authorized Person
Place: Seal of Industrial Unit
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એનેક્ષર

(કામદારોની/ સ્ટાફ્ની વિગત)

એકમન ુંનામ/સરનામ:ું

અ.નું કામદારનુનામ
ં ઘરન ુંસરનામુ ં મોબાઇલ ફોટો ઘર અને કઇ એકમમાુ ં એકમમાુથ
ં ી
નુબર
ં આઇ.ડી. એકમ રીતે આિિાનો ઘરે પરત
નુબર
ં િચ્ચેન ું આિશે સમય જિાનો
અંતર ? સમય

તારીખ : એકમના માલીકન ુંનામ સહી અનેસરનામું

સ્થળ : - મોબાઇલ નુબર

ં

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